HomeMy WebLinkAbout1356A WORKERS'COMPENSATION DECLARATION � ^�J �
��herel.� offirm thm I have a certificate of consent to seH . , f�(�L/
•.nsurg't-a certifica�e of Workers'Compensotion Inaurance,o� �6A°�3° ' � � f
a°�„�'=:°aPY'ha.so`,Se�.�°°,`°b�.> "�,�".B,e�, qppLICATION FOR PERMIT a ��'3�
Polity No. Company � Os .
❑Ceriified copy ia heraby fmnished. � . SEWER • SEWAGE OISPOSAL � ,�
COUNTY OF LOS ANGELES BUILDING AND SAfETV �r�
❑Ceriified copy is filed with the counry building inspec�ion , � �
depo��ment. .
oo�e nPPu<om FOR APPUCANT T FILL IN CONNECTION DATA
CERTIFICATE OF EXFM7TION FROM WORKERS' ��iw� , . .
� COMPENSATION�NSURANCE AODRE55 STATIpJ DEPrH
� (This saUion need no�6e complered if�he work involved by fhe �w,N�{piE pEFEaErKF � � U°�q
permit is for one hundred dollon(5100)or leay.) �«PpTV � °
I certify that in the�'pe�formance of�he work for which ihis ���SSi, ' d � *rvcacoNN�ior+ ,�r�T„faorn
Y. CVYB P.L. M.L TO F.L.
� permit is iasued,I�hall nof emptoy any penon in any monner
� w os io 6e ome subjetl to the Workera'Compenaotion Laws. owNca CO.IMP.NO. ' JOB NO.
��L TRVNK PERMIT NO. ' ROAO PFRMIT N0.
Date 6APPIicanl Z`ytli��� Aooa�ss .
NOTIC TO RICANT: If, ofror ma this Cenifimte of � , ar.ioAm. warvea eas��Nr RKORO.INSTR.ND. DATE
9 arv re�.No.�
Eaemption, yoo should become subjeU lo Ifia Workers' i�Ai .
� Compensation provisions of the lobor code,you musf forthwi�h ocscairrior� LOTNO. ' HWY.OR 5T.WIDfNING
�comply with such provisions or this permii shall be deemed
revoked. - . &oCa TiACT $TAii ENCROACHMEM
' UCENSED CONTRACTORS DECLARATION � N°.°r&o�s. a�RMiT r�o.
- SIZE OF lOT NO W ON l0T
I hareby afiirm fhat I om licensed under proviaions of Chap�e� us[a
9(commencing with Sec�io�7000)of Divieioa 3 of the Busi- em�ov�s - anaces
ness ond Proieasions Code,ond my 4icenae is in full force and
- CHeCI. ' CONTRACiOR , CONNfCfqN CNA0.�FEE . }
.{ ^ S.
Licanse Number4 /`�Q Lic.Class Z- qppqEu f REIMBUNSEMENT e � Q
COnlfOfl Dote � �� � D�SiRICI NO. GROUi MAP PNOCESSED BY V
CIiY TEt.NO. O/ Z
/ /, BN PG
❑I am exempt under5e<, oF tbe L.A.Co. i�Ns[np. (j 9 cuu C— '�' � O
H
Plumbing Code and/or Sec, of the ''p� DESCRiMiON OF wORK c�e wNqi /� W
NWY SEWFp CONNERING TO . DAif y a ')( VALIDATION d
Vli&I�$lWLR p d�p y�
- B.8 P.Code for ihe following reason PTIC 1ANK,SEE�AGE VIT OR � FNAI ?
� PIiS AN�/Ofi DfiAHi1E1D ' �
DOIS rypUSE SEWFR CONN[CiING 10 BY
PRIVAtE Y T M �
5i9�a��,e ca+Mc��oo,irowu a�o�.ow P
OWNER-BUILDER DECLARATION woac To�s�stvuee .
RF�pW PqC�E%T,DRAINFiEID
1 hereby affirm�hat I om exempt from the Contractor's License exTN_tEssroa,oavweu.nv�NHae . . � . . _.
Law for the foilowing reawn�SeC100�O3I.S,BUISf1055 O!I[I Pl0- ALTEF.REPAIR OR Al�NDOIJ NOUSE � .
fessions Code): 3EwEk Oa D�SrosA�SrSiEM , . . .
❑I,as owner of the proparfy,or my employees with woges as � ;�� �F(;f�
their sole compansalion,will da ihe work and the shucture � ' � .
is not intended or offered fo�wle(SaUion 7041,Business �' . e s t � �
and Professions Code). OWNER'S Permit 5 Q -
❑I,as owner of�he p�operty,am exdusively tonlracting with � AUTMORIZATION TOTAL FEE '�J � � °�l��5 Q
�iCBlls!(�[On11o[f0l5�O COnsfttlCf 1hB PlOjeC�($SCfiOn 70M,�- I HAVE Ai THiS DATE A CON1RACi WITH INf HFIiENJ NAMFD C NiRpC1pR 70 �
BV51��55 O�d ROfpSEIOnS COdOJ. � �ONNfCt TNE ABOVE pESCFIBED E%ISiING pWEIIING TO TME iUBLIC SfWfR, � c c C�'.�5�L
CONSTRUCTION LENDING AGENCY � � , - - - �
I hereby affirm thar there is a tonslruction lending agency S�GNf�THiS DAVOF t9_ d C L�—�G fi
far the performonte of fhe work for which ihis permit is ' ��R� ' � �
ISEUBCJ(SCC.304�,Clv.C.]. OWNERSAGENT �
ADORE55 . . .
lender's Nome
Lander's Address - - �� ' '���� "
I ca�lify ihat I hava read ihis applimtion and state that ihe � �
above informotion is correct.I ogree to comply wiih all Couny � " � ' - �
ordinances and State lows requlot�mbing and Sewers,
and hereby oihorin'repr,seniQY es this Counly to ler � - . - � � �-
upon the q�ve- �ion prop fy, mspection purp es. � .
� �as' &.�
afV e Ot Parmittea Date SEE REVERSE FOR E%PLANAiORY LANGUAGE
• INSPECTOR'S NOTES OWNER-BUILDER DECLARA'1'ION
APPROVALS onre iHsxcroR•s ucrian� I bereby affirm chat I am e�mpc from the Contraetor's
� Licence Law for the lolbwia;re�eon/S�tfmw 7031.5,
�w Nouse stwEe ��/ '. �. . . . . . ..
oorwe�.��cw.i«+u . Br:;«Bss a�d tivJsr,00w Cod.k Awy eisy o.co..w:y
wnu�+c oa woaic - - wbirb rcguira�a pem�lt w mwa�ut,alMr,iie�prova.
� � demolisb,or wair ary shweMn,prior eo iRc h�wwce,
�/ORp1AN�f1FlDTlSj ._. . - ... . . .. .. _� -.. . .... _ . _ . 6jsU feqYilic ibY R�It JOf JYCb�I/Nqt i0 Jile a
CFSSVOOI❑ ORYWELL Q .. . . . . Slgl{B(�SiYt/�DMI 3bWt jlf ji�lCfl�tld jMl/SflOwt!O �C
. , ' p/OU%SfOfS OJ t11Y CiOA/IdCfOf�3 1.;LYNQ/I.014�ri��If 9
. � artw.Atv,�w.sew:c oR _ . .. � (con�n�awciMg suitb S«fiow 7000/ul IX�idos 3 oJ cbe
ff1MAGE DISPOSV SYSTEM '_ ' '"' .
o�a RW N+o Busi«av aAd PrvJ�sdosr Codal or tbat bs ir exwwpe
�anoav�m[scw[R �� tberaJrons awd rLe bivaJor.sh�dlgd exnsydw.Awy
e�auxi¢vric ravus p +�idaaaoK uJSactior/7031.5 by exy�ppliea�tJorapenwit
7¢s rrc s O �assPoots O � - tubjecYs tbe opplicaw�w a cioflprwaity of wt riwre tbow
. _.
. . .-- -.. .. . . /lue Iwrdnd doUott(,fSdO�r �. .
�I,as the owaer o�t6e properq wIll do the work.aad
the sttuctnte is not 3ntended or o�ered for u1e.
(Sec. 70�4;Bwir�e*s�d RvJesdoas Cadr:Tbr Cas-
. . . . . . . aaclor's LJceu�Lan doa�ol apply b aw ow�sr oj
- . . . . _ . - -- �P�Y wbo brildr or iuMprowr tb�now.ard wba doaa
. srcb wior,i binu�j/prwdd�d tbsf trcb�rwprow/neNa
aro»ot iwtt�drd or ofJind Jo►ul�..%lwtwwr.tbe
. .. . . . . . brild&y�or iiwprnu�wwat ir m/d v+ifbr�or�yaar oJ
aouPl.t:wt tbr muw�rb�ild�►wiU.bow tb�bwdow
- � . aj prouirg tbaJ b�r dfd�ot 6rild or ierprow jor ebe
PY���1
_ - I am-exempt uader Sec. ,
. B&P.C.for this reason
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Date
Owner
INSPEROR'S NOTES - '
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